W. Va. Code R. § 114-95-6

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-95-6 - Operational Requirements

6.1. A utilization review program shall use documented clinical review criteria that are based on sound clinical evidence and are evaluated periodically to assure ongoing efficacy. An issuer may develop its own clinical review criteria or it may purchase or license clinical review criteria from qualified vendors. An issuer shall make available its clinical review criteria upon request by a person authorized by the Commissioner or by statute or legislative rule to receive such information.

6.2. Qualified health care professionals shall administer the utilization review program and oversee utilization review decisions. A clinical peer shall evaluate the clinical appropriateness of adverse determinations.

6.3.Exhaustion.

6.3.a. Whenever an issuer fails to adhere to the requirements of section 7 or 8 with respect to making utilization review and benefit determinations of a benefit request or claim, the covered person shall be deemed to have exhausted the provisions of this rule and may file a request for external review in accordance with the procedures outlined in W.Va. Code of St. R. § 114-97-1et seq.

6.3.a.1. Notwithstanding subdivision 6.3.a, the provisions of sections 7 or 8 of this rule shall not be deemed exhausted based on a de minimis violation that does not cause, and is not likely to cause, prejudice or harm to the covered person as long as the issuer demonstrates that the violation was for good cause or due to matters beyond its control and that the violation occurred in the context of an ongoing, good faith exchange of information between the issuer and the covered person.

6.3.a.2. The exception described in paragraph 6.3.a.1 is inapplicable if the violation is part of a pattern or practice of violations by the issuer.

6.3.a.3. Within ten days of receiving a request from a covered person, an issuer shall provide a written explanation of why it believes that any alleged violation of sections 7 or 8 of this rule does not constitute a sufficient basis to trigger the exhaustion provisions of subdivision 6.3.a.

6.3.a.4. The Commissioner shall resolve any issues raised by an issuer as to whether a covered person may, in accordance with paragraph 6.3.a.1, be deemed to have exhausted the provisions of this rule, and the Commissioner's written notice of a determination that such exhaustion requirements have not been met shall also inform the covered person that he or she may resubmit and, as appropriate, pursue a review of the benefit request or claim under this rule or file a grievance pursuant to W.Va. Code of St. R. § 114-96-1et seq.

6.3.a.5. For purposes of calculating the time period for refiling the benefit request or claim, the time period shall begin to run upon the covered person's receipt of the notice of opportunity to resubmit.

6.4. An issuer shall have a process to ensure that utilization reviewers apply clinical review criteria in conducting utilization review consistently.

6.5. An issuer shall routinely assess the effectiveness and efficiency of its utilization review program.

6.6. An issuer's data systems shall be sufficient to support utilization review program activities and to generate management reports to enable the issuer to monitor and manage health care services effectively.

6.7. If an issuer delegates any utilization review activities to a utilization review organization, the issuer shall maintain adequate oversight, which shall include:

6.7.a. A written description of the utilization review organization's activities and responsibilities, including reporting requirements;

6.7.b. Evidence of formal approval of the utilization review organization's program by the issuer; and

6.7.c. A process by which the issuer evaluates the performance of the utilization review organization.

6.8. The issuer shall coordinate the utilization review program with other medical management activity conducted by the issuer, such as quality assurance, credentialing, provider contracting, data reporting, grievance procedures, processes for assessing member satisfaction and risk management.

6.9. An issuer shall provide covered persons and participating providers with access to its review staff by a toll-free telephone number.

6.10. When conducting utilization review, the issuer shall collect only the information necessary, including pertinent clinical information, to make the utilization review or benefit determination.

6.11. In conducting utilization review, the issuer shall ensure that the review is conducted in a manner to ensure the independence and impartiality of the individuals involved in making the utilization review or benefit determination, including not basing decisions regarding hiring, compensation, termination, promotion or other similar matters upon the likelihood that the individual will support the denial of benefits.

W. Va. Code R. § 114-95-6